USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1904-1906 > Part 17
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of Father, Maiden Name and Birthplace of Mother, Forst Oficer Cemetery
Place of Interment,
Summer Floyd
Undertaker. 18 Herman &Sweet
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Boston,
Och 19h
1900 -
Name and Age of Deceased, Eso, Young Age, 39 years.
Date and Och . 18h 1pts
vinteropp. 16702169
Disease
Contributing cause,. Vccideut.
Chief cause,
Duration Contributing cause, ...
I certify that the above is true to the best of my knowledge and belief.
Name and Residence 1
of Physician, 5 Francis a. Mazzio M.D.
* If an institution, state how long an inmate and previous residence.
Wanthope Street
Place of Death,* - Chief cause
ann Baker-Canada
٨
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME
Clara, L. Herbert
Registered No.
Place of Death *
133 Johnson aver Huchet mais
Date of Death
Cache 19- 1905
Age
82
.. years
9
months
10
.days
STATISTICAL DETAILS
SEX Female
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
fordow
Compara Partridge.
HUSBAND'S NAME + 900 . av. Herbert.
BIRTHPLACE #
NAME OF
FATHER
Harry Partridge
BIRTHPLACE
OF FATHER+
MAIDEN NAME
OF MOTHER
Polly Cook
BIRTHPLACE OF MOTHER + * Provincetown mars
OCCUPATION
INFORMANT § Daughter -
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last 190.5.to illness, from Och, qtx och. 18Th 1905 that to the best of my knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows : Primary : Bright- Niveau
.(DURATION). . DAYS
Contributory :
aldage
(DURATION) .DAYS
(Signed)
N. B. Dorman
M.D.
Get. 19 th
1905 ... (Address)
Wwithop Mart.
SPECIAL INFORMATION only for Hospitals, Institutions, Translents, or Recent Residents.
Former or Usual Residence
How long at
Place of Death ?
Days
Where was disease contracted, if not at place of death ?
Filed
190
Clerk
* City or town, street and number, If any. If death occurs away from USUAL RESI DENCE, give facts called for under "Special Information," If In a Hospital of Institution, give Its NAME Instead of street and number.
t In case of married or divorced woman, or widow.
* State or country; also city, town or county, If known.
§ Name and address of person giving statistical details. | Name of cemetery.
PLACE OF BURIAL OR REMOVAL II
DATE OF BURIAL
Cad-19
190
UNDERTAKER 6.1. Jemmin
ADDRESS .
INC OR POR ATE
IROP
PSF CHURCH
A
TOWN OF WINTHROP
(404-37-J.M.]
Permit No.
RETURN OF DEATH. BOSTON, MASS.
Date of Death,
October 25"1905
Name in full, adele C. Gherman
(If a married or divorced woman give maiden name, also name of husband.)
Sex, Female
Color,:
Othite-
Condition,
Single
(White, Black, Mixed, Chinese,
Indian, etc.)
(Single, Married, Widowed or
Divorced. )
31 Years , 5 Months, Days. Occupation, arhome
Residence,
Otanthrope Glass
Ward ...
Place of Death, 89, Oderman Street Hinthury.
Place of Birth,
Wellfleet Mass" Date of Birth,
(State year, month and day.)
Name and Birthplace ? of Father,
Muchville Dr. Freeman- Wellfleet
Maiden Name and Emma C. Higgins-Wellfleet
Birthplace of Mother, )
Place of Interment, Orelequer Mass
Summer Floyd
Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH. Minttrop October 26" 1905.
Name and Age
of Deceased,
adele G. freeman
Age, 31 years. 5 mos
Date and
Cette 25" 1905-89 Overman Rice Acnitrop
Place of Death,"
Chief cause,
asthma
Disease
Contributing cause,
Cardias weakness
Chief cause,
since birth.
Duration -
Contributing cause,
4 weeks
I certify that the above is true to the best of my knowledge and belief.
Name and Residence }
21 mal col
M.D.
of Physician,
* If an institution, atate how long an inmate and previous residence.
21
A True Copy Attest: Carla Vitale
Town Clerk 000
D
erk
SI
[4.'04.37.I.M.]
Permit No.
RETURN OF DEATH. BOSTON, MASS.
Date of Death, October 25"1905
Name in full, adele S. Openair
(If a married or divorced woman give maiden name, also name of husband.)
Sex, Female Color, While- Condition, Single
(White, Black, Mixed, Chinese, Indian, etc.) arhome
Residence, Stinthrop glass
Ward,/
Place of Death, 89, Oderman Street Winthrop.
Place of Birth, Wellfleet Mass"> Date of Birth,
(State year, month and day.)
Name and Birthplace ) of Father,
alville Dr. Freeman - Wellfleet
Maiden Name and Comma Ro. Higgins-Wellfleet
Birthplace of Mother,
Place of Interment, Orellquet mass
Summer Floyd
Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Winthrop October 26" 1905.
Boston,-
Name and Age ? of Deceased, adele G. Freeman
Age, 31 years. 5 mos
Date and Celler 25 " 1905 - 89 Otermin Ruce Ninitrop Place of Death,* - Chief cause, asthma Disease Contributing cause,. Cardias weakness
Chief cause, since birth.
Duration Contributing cause, 4 weeks
I certify that the above is true to the best of my knowledge and belief.
Name and Residence ? of Physician, M.D.
* If an Institution, state how long an inmate and previous residence.
21
(Single, Married, Widowed or Divorced.)
Age, 31 Years, 5 Months, Days. Occupation,
[4.'04.37.I.M.]
Permit No.
RETURN OF DEATH. BOSTON, MASS.
Date of Death,. October 25"1905
Name in full, adele G. Freeman
(If a married or divorced woman give maiden name, also name of husband.)
Sex, Female Color, Orhite-
Condition, Single
(Single, Married, Widowed or Divorced.)
Age, 31 Years, 5 Months, Days. Occupation,
Residence, Stinthrop Mass
Ward,
Place of Death, 89, Oferman Sheet Winthrop
(State year, month and day.)
Place of Birth, Wellfleet Mass" Date of Birth,
Name and Birthplace ? of Father, Maiden Name and 1 Birthplace of Mother,
Melville J. Freeman - Wellfleet
Comma lo. Higgins -Wellfleet
Place of Interment, Orelequet mass
Summer Floyd
Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Hinttrop October 26" 1905.
Name and Age ?
of Deceased, adele G. Freeman
Age, 31 years. 5 mos
Date and Cette 25 " 1905- 89 Oxtermin Rice Huntrop
Place of Death,* asthma Disease
Contributing cause,
Chief cause, Cardias weakness
Chief cause, since birth.
Duration - Contributing cause,. 4 weeks
I certify that the above is true to the best of my knowledge and belief.
Name and Residence ! of Physician, 21 Mal chef M.D.
* If an Institution, state how long an Inmate and previous residence.
(White, Black, Mixed, Chinese, Indian, etc.) arhome
98
[[4.'04-37-LM.]
Permit No.
RETURN, OF DEATH. BOSTON, MASS.
1
Date of Death,
nr. 13.05.
Name in full,
Sex,
Color
Hht
Condition,
(White, Black, Mixed, Chinese, Indian, etc.)
(Single, Married, Widowed or Divorced.) Soldater.
Age, 40 Years, X Months, X Days.
Residence,
Occupation,. 189 Boylston S. P.
Ward,
Place of Death,
Took Banks Manthrow Mass.
(State year, month and day.)
Place of Birth, thefind.
Date of Birth,
army Ireland
.Name and Birthplace ) of Father, Maiden Name and Birthplace of Mother, S Place of Interment,
Catharina Conway
Bahar
Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Booten,.
4h. Banks Hair
190 5
of Deceased, 3 4thn & Manning Age, 40 years.
Date and Fl. Bandas Man. 400. 13, 19851
Place of Death,*
L Chief cause, Chimie Careundry mations diphritis ..
Disease
Contributing cause, Cunti Excavation
Chief cause,
Duration
Contributing cause,
6
I certify that the above is true to the best of my knowledge and belief.
Name and Residence ? of Physician,
* If an Institution, state how long an inmate and previous residence.
Cafe tant cushion M.D.
921
Name and Age
John manu
"Single
(If a married or divorced woman give maiden name, also name of husband.)
[4.'04.37-J.M.]
Permit No.
RETURN OF DEATH. Printtrop BOSTON, MASS.
Date of Death,
ONovember 15"19.05
Name in full, Josiah Fitz 3d
(If a married or divorced woman give maiden name, also name of husband.)
Sex, male Color, White
Condition, married
(Single, Married, Widowed or
Divorced.)
Age, 74 Years, ~ Months,. 19 Days.
(White, Black, Mixed, Chinese, Indian, etc.) Occupation Hotel Parkevictor
Residence, Winthrop, Otiglande
Ward,
Place of Death, 48 Janviere Avenue (Ototal Argyle) Col26"1831
Place of Birth,
Salem Mass
Date of Birth,
Ariah Fits 22 = Beverly mass
Name and Birthplace of Father, Maiden Name and Sarah P. Morgan=Salem mass Birthplace of Mother, Pine Gasse Cemetery Lynn Mass
Place of Interment,
Summer Floyd
Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Winthropfor. November 16" 1905.
Name and Age ) of Deceased, Dosiah File 3d
Age, 74 years. 21 Days
Date and @November 15" 1905-Grotere avenue
Place of Death,*
Chief cause, Chine Interstitial (hephotos
Disease
Contributing cause,
Chief cause,
6 mm
Duration
Contributing cause,
I certify that the above is true to the best of my knowledge and belief.
Nume and Residence )
of Physician,
(31 Met cal
M.D.
* If an institution, state how long an Inmate and previous residence.
(State year, month and day.)
[4.'04.37.J.M.]
Permit No.
Anthropo
BOSTON, MASS.
Date of Death, Ofor 16 "1905
Name in full, Georgianna Pierce
(If a married or divorced woman give maiden name, also name of husband.)
Sex, Female Color, White Condition, Sridom
(White, Black, Mixed, Chinese, Indian, etc.)
(Single, Married, Widowed or Divorced.)
Age, 75 Years, 6 Months, 19 Days. Occupation,
Residence,
mass Ward,
Place of Death, 16H Winthrop, Sheel
Place of Birth, Nova Scotia"
(State year, month and day.)
Date of Birth, May 3" 1830
Name and Birthplace ? Unknown
of Father, Maiden Name and Birthplace of Mother, Place of Interment,
Surmer Floyd
Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
eller gian Eurgramma
2/101.17 190 9
Name and Age ) of Deceased ,
Date and Mar. 16. 1905
verce ..... Age, years.
-
Place of Death,* Myocarditis + Pulmonary congration, Chief cause, ... Disease Malaria
Contributing cause,
Chief cause,
Duration Contributing cause,. Five (5) mets
I certify that the above is true to the best of my knowledge and belief.
Name and Residence ) of Physician, 5
M.D.
307 Jan It 8
* If an Institution, state how long an Inmate and previous residence.
RETURN OF DEATH.
[4.'04-37. I.M.]
Permit No.
RETURN OF DEATH. BOSTON, MASS.
Date of Death,
December 1" 1905
Name in full, ..
Denge S, Jumble
(If a married or divorced woman give maiden name, also name of husband.)
Sex, Male Color White Condition, married
(White, Black, Mixed, Chinese, Indian, etc.)
(Single, Married, Widowed or Divorced.) Salesman
Age, 66 Years, ~Months, Days.
Occupation,
Residence, Minttwo 10
mass
Ward,
Place of Death, 17 Sargent Street
Place of Birth, Halifax W.S. Date of Birth,
(State year, month and day.) Jeje 26
Denge Yumbee - England
Name and Birthplace ? of Father, Maiden Name and Birthplace of Mother,
Wany a. Pettigrew- Otalifar NS,
Place of Interment, IV interop Cemetery
Summer Floyd
Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Winthrop Boston, !. December 1" 1905.
Name and Age )
of Deceased, Serge S, Cumbre
Age, 66 years.
Date and Place of Death,* ? December 11905-17 Sargent Street
Chief cause,.
Disease Contributing cause,.
Chief cause, Six days - ...... ......
Duration Contributing cause, .. .
I certify that the above is true to the best of my knowledge and belief.
Name and Residence ) of Physician, THEJohnson M.D.
· If an Institution, state how long an Inmate and previous residence.
4.'04.37. I.M.]
Permit No. ....
RETURN OF DEATH. Mintha BOSTON, MASS.
Date of Death, December 2" 1905
Name in full, Mehitable. R.O vagy.
(If a married or divorced woman give maiden name, also name of husband.)
Sex, Otemaler Color, White-
(White, Black, Mixed, Chinese, Indian, etc.) Condition, Widowed
(Single, Married, Widowed or Divorced.)
Age, 76 Years, 2 Months, 22 Days. Occupation,
Residence, Winthrop Mass
Ward,
Place of Death, 196 Pleasant Street Or Buchanan el
Place of Birth, Burry manie
Date of Birth, Sepet 10"1829
Ederekich
Unknown
Name and Birthplace of Father, Maiden Name and Birthplace of Mother,
Unknow
Place of Interment,
Summer Floyd
Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Hanthof December 2" Boston,
1905.
Name and Age ? of Deceased, Mehilable Pourgy Age, years.
Date and December 20 1905 -196 Pleasant Sheet.
Place of Death,*
Chief cause, .. Senility
Disease Contributing cause, Chief cause,
Duration Contributing cause,
I certify that the above is true to the best of my knowledge and belief.
Name and Residence / of Physician, M.D.
* If an Institution, state how long an Inmate and previous residence.
(State year, month and day.)
Mehitable, reworgy
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME
Athun 6. Moreland
.Registered No.
14 8
Place of Death *
9 Sagamore VE.
Date of Death
Dec. 9th
1905-
Age
years
4
months.
23
days
STATISTICAL DETAILS
SEX
m
COLOR
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
Single
MAIDEN NAME Ť HUSBAND'S NAME +
BIRTHPLACE #
9 Sagamore UNE.
NAME OF
FATHER
Thank C. Moreland
BIRTHPLACE
OF FATHER៛
Lmport n. S.
MAIDEN NAME
OF MOTHER
Mary E. Harthy
BIRTHPLACE
OF MOTHER #
East Boston.
OCCUPATION
INFORMANT §
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from
190
.to
.190
that to the best of my knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows
Primary :
Perforation of Binvels
Peritonitis
4 weeks
(DURATION).
DAYS
Contributory :
(DURATION) . DAYS
(Signed)
Biometcall
M.D.
the 11 1905 (Address)
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
Former or
Usual Residence
How long at
Place of Death ?
Days
Where was disease contracted, if not at place of death ?
Filed
190
Clerk
PLACE OF BURIAL OR REMOVAL II
Winthrop
DATE OF BURIAL
190. .. 5
UNDERTAKER
6. G. Brown
ADDRESS
* City or town, street and number, if any, If death occurs away from USUAL RESI- DENCE, give facts called for under "Special Information." If in a Hospital or Institution, give its NAME instead of street and number.
t In case of married or divorced woman, or widow. # State or country ; also city, town or county, if known.
§ Name and address of person giving statisticai details. Il Name of cemetery.
[4.'04-37-LM.]
Permit No ..
RETURN OF DEATH. BOSTON, MASS.
Date of Death,. December 15" 1905
Name in full, Louise taggato
(If a married or divorced woman give maiden name, also name of husband.)
Sex, Female Color
(White, Black, Mixed, Chinese, Indian, etc.) Condition, Single
(Single, Married, Widowed or Divorced.)
Age, 78 Years, 11 Months, Days. Occupation,
Residence,. Point Shirley Skintrop
Ward,
Place of Death, 11 11
(State year, month and day.)
Place of Birth,
Charlestermi Mass Date of Birth, Jan 15"1827
Name and Birthplace ? of Father,
David Haggereton- Lukefue England Maiden Name and May ami Farmcee- Fitchburg mas
Birthplace of Mother,
Place of Interment, Mount Hoje Camely
Sammen Floyd
Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Name and Age )
Amisa Hanjesh
Age, 78 years. 11 more
Date and December 15"1905, Point Schulen
July Place of Death,* Disease
Chief cause, Mitral Ateraxis - Contributing cause, ..
Chief cause, Kend denly
Duration Contributing cause,.
I certify that the above is true to the best of my knowledge and belief.
Name and Residence ? of Physician, Ml. Partin, Hanetiolo M.D.
· If an institution, state how long an Inmate and previofis/residence.
D21
Boston, Lecamber 15 1905.
of Deceased, niza
COMMONWEALTH OF MASSACHUSETTS
RETURN
OF A DEATH
Many. ann McInnis
FULL NAME
.Registered No.
Place of Death *
maçãallo Horbital Windterol
mais
Date of Death
December. 17, 1905:
Age.
36
. years
3
months
.days
STATISTICAL DETAILS
SEX Female
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
.
MAIDEN NAME + HUSBAND'S NAME +
BIRTHPLACE #
while creek
NAME OF FATHER angus. Ma quis
BIRTHPLACE OF FATHER# Lastlan l
MAIDEN NAME
OF MOTHER
Marquette Mc Donald
BIRTHPLACE
OF MOTHER#
Cafe Bricó
Leiteles Creek U.S.
OCCUPATION
INFORMANT § Employer
PHYSICIAN'S CERTIFICATE
| HEREBY CERTIFY that I attended deceased during last
illness, from.
190 ..... to
190
that to the best of my knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows : Primary : Pere Obscur
4 w/5
(DURATION)
. DAYS
Contributory :
aberation
(DURATION) 2
. DAYS
(Signed)
1
De 19 1905 (Address)
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
Former or
Usual Residence
Shorty str.
How long at
2
Days
Where was disease contracted,
If not at place of death ?
not Kun
Filed
190
Clerk
PLACE OF BURIAL OR REMOVAL II
DATE OF BURIAL
M.S.
190.
ADDRESS
UNDERTAKER C.R. Buna
* City or town, street and number, if any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Special Information." if in a Hospital or Institution, give its NAME instead of street and number.
t In case of married or divorced woman, or widow.
# State or country; also city, town or county, If known.
§ Name and address of person giving statistical details. || Name of cemetery.
ALL NAMES TO BE IN FULL
M.D.
Place of Death ?
[4.'04-37-LM.]
Permit No.
RETURN OF DEATH. 1 BOSTON, MASS. -
Name in full,
(If a married or divorced woman give maiden name, also name of husband.)
(White, Black, Mixed, Chinese, Indian, etc.) Condition, Sex, Female Color, White
Age, 46 Years, ~Months, ~Days.
Occupation,
Residence, Winthrop mass Ward,
Place of Death, 7 Belcher Street
Place of Birth,
Stora Bestia
Date of Birth,:
State year, month and day.) Jamay 16" 199
Tová Sentía
Name and Birthplace ? of Father,
Unkem
Ctora Scalia
Maiden Name and Birthplace of Mother, Place of Interment, Silgard mass
Summer Floyd
Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
1905.
Name and Age of Deceased, Glizabeth ada Symonds Age, 46 years.
Date and December 18" 1905 - 7 Belcher Steel
Place of Death,*
Chief cause, ..... Heart Disease
Disease Contributing cause,
Chief cause, ..... Half hour
Duration Contributing cause,
I certify that the above is true to the best of my knowledge and belief. Name and Residence ) of Physician,
* If an Institution, state how long an Inmate and previous residence.
21
Mass M.D.
Date of Death, December 18" 1905 Elizabeth ada Symonds
(Single, Married, Widowed or Divorced.)
[4.'04-37-LM.]
Permit No. ....
RETURN OF DEATH. BOSTON, MASS.
Date of Death,.
December 28" 1905
Name in full,
Mielantha b. Studley
(If a married or divorced woman give maiden name, also name of husband.)
Sex,
Color, White
Condition, Didmed
(Single, Married, Widowed or Divorced.)
Age, ..
Months,
18 Days.
(White, Black, Mixed, Chinese, Indian, etc.) Occupation,
Residence,
5 Park avenue Winthrop Mass Ward,
Place of Death, 11 11
(State year, month and day.)
Place of Birth,
South Yarmouth
Date of Birth,
Name and Birthplace ? of Father,
abraham, Ormele
Maiden Name and Charlotte Berry Yarmouth Mass
Birthplace of Mother, )
Place of Interment,
Trest Dennis Mass
Summer floyd
Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Boston,
December 28 " 1905.
Name and Age of Deceased, : Melintha lo, Studley Age, 84 years. 2 mis 18da
Date and December 28. 1905 5 Park avenue
Place of Death,* S L Chief eause, .. Annamaria
Disease 3 Contributing cause, Aenitity?
Chief cause,
Duration - Contributing cause,
I certify that the above is true to the best of my knowledge and belief.
Name and Residence ) of Physician, S A.l. Carter Nexthroto M.D.
* If an institution, state how long an Inmate and previous residence.
:[4.'04-37-LM.]
Permit No.
RETURN OF DEATH. BOSTON, MASS.
Date of Death, Dec 29/05
Name in full,
Jamie a. Grillow
(If a married or divorced woman give maiden name, also name of husband.)
Sex, Color
(White, Black, Mixed, Chinese, (Single, Married, Widowed-or Divorced.)
Age, 45 Years, -Months, ~ Days.
Occupation,. name
Residence, ... 61 Somersett are Worth Ward,
Place of Death, Winetrof
Place of Birth, Ohio "Dewit" Dat
(State year, month and day.)
Date of Birth,
Name and Birthplace James
cheland
anna Milne Scotland
of Father, Maiden Name and Birthplace of Mother,s Place of Interment, St Peters bem. Hudson lety New Jersey That, I. Dane Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Boston,
Dec. 29
190 5.
Name and Age ? Dames a britton
of Deceased,
Date and 61 Somerset any
Place of Death,* Chief cause, ... Levermotor amila
Insanity
-
Disease
Contributing cause, ....
Chief cause, 2 years Duration Contributing cause,
I certify that the above is true to the best of my knowledge and belief.
Name and Residence ? of Physician, M.D.
* If an Institution, state how long an Inmate and previous residence.
21
Age, 45 years.
Indian, etc.) Condition, S
COMMONWEALTH OF MASSACHUSETTS
11 Harol, Pluss
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
francis ), los
Registered No.
Place of )
win It ut isthat has
Death *
5
Residence
Marthain
Age
3.4
.. years.
10
.months ..
.days
STATISTICAL DETAILS
SEX Hemair
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME Ť
Francis
martine
HUSBAND'S NAME }
Altin Bij lose
BIRTHPLACE #
Bustin Mass
NAME OF
FATHER
fotoe Mail.
BIRTHPLACE
OF FATHER$
Boston thus
MAIDEN NAME
OF MOTHER
Catherine
BIRTHPLACE
OF MOTHER#
Boston Mas
OCCUPATION
INFORMANT § Mes Ümern / Daughter , C
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from Dept. 15 190g ... to Dec. 30. 1906, that to the best of my knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows : Primary : Diabetes
Un definite
(DURATION). DAYS
Contributovy :
Micrae Regurgitation
Indefinite (DURATION) .. DAYS
(Signed)
H.J. Partir
M.D.
I am. 1. 1900 (Address)
1
Winthrop.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
How long at
Place of Death ?
. years.
..... .
months ..
days
Where was disease contracted,
If not at place of death ?
Filed
190
Clerk
PLACE OF BURIAL OR REMOVAL II
Fix Freata Cimreling Walliam
DATE OF BURIAL
Jazy 2
190.31
UNDERTAKER
George W, lovon
ADDRESS
Halitam mass
* City or town, street and number, If any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Speclal Information." If In a Hospital or Institution, give Its NAME instead of street and number.
t In case of married or divorced woman, or widow.
# State or country ; also city, town or county, If known.
§ Name and address of person giving statistical detalls. Il Name of cemetery.
ALL NAMES TO BE IN FULL
Date of
20%
190
Death
5
FORM C.
Commonwealth of Massachusetts.
No.
RETURN OF A DEATH. To the Clerk of the City or Town in which the death occurred.
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Name,
Sex, 2
il leu .. Color,
Date of Death,
LER 20 c 1905; Age, 3/ Years,
Months,
Days.
Maiden Name, { If married, widowed ) or divorced.
Husband's Name,
Daniel 7, -Quick/4L
Single, Married, Widowed or Divorced, married Occupation, Drinkstic
*Residence, { If out of town, )
¿ also state fully. §
Place of Birth,
Irland
*Place of Death,
Name and Birthplace of Father, tousling Donovan Ferland
Maiden Name and Birthplace of Mother, DELLOVU
Place of Interment, (Give name of Cemetery),
1
Dated at
on
190 元 1 Signature and place of business of Undertaker.
(146 2 Printerob 27V
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceased, t
Andia Buckles
Age, 3 7Y.
.M.
Place and Date of Death,
( Primary, Disease or Cause ) of Death, # Secondary,
Duration,
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence of Certifying l'hysician.
M. D.
Date of Certificate, 190
· Give also street and number, if any. t Give sex of Infant not named. If still-born, so state.
: if a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
died at ...
80, would st Remy.
the 30
190 5 .-
Duration,
200
No.
RETURN OF THE DEATH
OF
at
Date,
190.
Filed,
190 ..
[EXTRACTS FROM CHAPTER 444, ACTS OF 1897.]
SECTION 6. Every householder in whose house a death occurs, the oldest person next of kin present at the time of the death of any of his kindred, or the person in charge of an institution in which a death occurs, shall, within five days after the date of such a death, give notice thereof to the board of health or to the clerk of the city or town in which the death occurred.
SECTION 7. The commanding officer of a vessel shall give notice of the death of any person under his charge to the board of health or to the clerk of the city or town within the Commonwealth at which his vessel first arrives after such death.
SECTION 8. Penalty for neglect to comply with the requirements of sections 6 and 7, five dollars.
SECTION 10. A physician who has attended a person during his last illness shall forthwith after the death of said person, upon request, furnish for registration a certificate setting forth the required facts.
SECTION 11. In case the deceased was a soldier who served in the war of the rebellion, give both the primary and the secondary or immediate cause of death as nearly as he can state the same. Penalty for refusal or neglect, ten dollars.
SECTION 12. Any person having charge of the funereal rites preliminary to the interment of a human body shall obtain thic physician's certificate made in accordance with section 10, and return it, together with the facts required by section 1, to the board of health or to the clerk of the city or town in which the death occurred.
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